CHAPTER 9 TERMS – Flashcards
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AUDIT
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To examine and review a group of patients' records.
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CHEDDAR
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The format of medical records documentation takes the SOAP format further. Stands For: Chief complaint, History, Examination, Details, Drug and dosage, Assessment, Return visit
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DOCUMENTATION
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The recording of information in a patient's medical record; includes detailed notes about each contact with the patient and about the treatment plan, patient progress, and treatment outcomes.
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ELECTRONIC HEALTH RECORDS (EHR)
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Patient health record created and stored on a computer or other electronic storage device. Also known as electronic medical records.
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ELECTRONIC MEDICAL RECORDS (EMR)
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Patient medical record created and stored on a computer or other electronic storage device.
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INDIVIDUAL IDENTIFIABLE HEALTH INFORMATION (IIHI)-
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Any part of an individual's health information, including demographic information, collected from an individual that is received by a covered entity. ( health care provider)
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INFORMED CONSENT FORM
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A form that verifies that a patient understands the offered treatment and its possible outcomes or side effects.
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NONCOMPLIANT
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Describes a patient who does not follow the medical advice given
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OBJECTIVE
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Pertaining to data that is readily apparent and measurable, such as vital signs, test results, or physical examination findings.
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PATIENT RECORD/CHART
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A compilation of important information about a patient's medical history and present condition.
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POMR
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The problem oriented medical record system- for keeping patients' charts. Information in a POMR includes the database of information about the patient and the patient's condition, the Problem list, the diagnostic and treatment plan, and progress notes.
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SIGN
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An objective or external factor, such as blood pressure, rash, or swelling, that can be seen or felt by the physician or measured by an instrument.
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SOAP
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An approach to medical records documentation that documents information in the following Order: S(subjective data), O(objective data), A(assessment), P(plan of action)
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SUBJECTIVE
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Pertaining to data that is obtained from conversation with a person or patient.
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SYMPTOM
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A subjective, or internal, condition felt by a patient, such as pain, nausea, or something the doctor cannot see nor measure.
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TRANSCRIPTION
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The transforming of spoken notes into accurate written form.
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TRANSFER
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To give something, such as information, to another party outside the doctor's office.
